Provider Demographics
NPI:1558953414
Name:POWELL, DAVID G
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:G
Last Name:POWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4343 HONEY LOCUST LN
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45432-1821
Mailing Address - Country:US
Mailing Address - Phone:937-941-1392
Mailing Address - Fax:
Practice Address - Street 1:4343 HONEY LOCUST LN
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45432-1821
Practice Address - Country:US
Practice Address - Phone:937-941-1392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-10
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH104780061899Medicaid